The Thyroid Nodule Surgical or Non-Surgical Management

A. Darrell Tackett, MD, FACS

While malignancies of the thyroid are rare and for the most part indolent in nature, thyroid nodules are fairly common affecting 5% to 10% of the population. Since less than 5% of nodules contain cancer, the challenge for clinicians is to make a prompt and effective diagnosis without subjecting the majority of patients to uncomfortable and expensive studies or surgery.

The most important single study in the analysis of thyroid nodules is the fine needle aspirate. In experienced hands the FNA has significantly reduced the incidence of surgery for benign disease with current yield of cancer in surgically treated patients at 45% to 50% as opposed to 10% to 15% in the past. The only circumstance in which FNA should be avoided is when familial medullary carcinoma or MEN-II syndrome is suspected to prevent possible needle tract cancer dissemination.

The frequencies of FNA findings are 70% to 75% benign, 4% to 5% malignant, 10% to 15% suspicious for malignancy and 10% to 15% inadequate for diagnosis. Benign nodules can be observed with repeat FNA in six months or if the nodule increases in size under observation. Malignant nodules should undergo the surgery appropriate for the type of cancer identified. Indeterminate of inadequately sampled nodules should undergo repeat aspiration. Nodules with tow indeterminate aspirations or those with aspirates suspicious for malignancy should have ipsilateral thyroidectomy including resection of the isthmus with subsequent therapy determined by intraoperative pathologic diagnosis.

Although FNA has reduced the incidence of operation for benign thyroid nodules, there are some situations in which expedited surgical management is advisable despite FNA evidence for benign disease. These situations are listed in table 1.

Surgical Indications (table 1)

  • Cystic nodules with persistent recurrence or bloody cyst fluid
  • Family history of papillary carcinoma, MEN-II or medullary carcinoma
  • Patients with a history of ionizing radiation exposure to the neck
  • Patients less than 20 years of age or greater than 45 years (especially men)
  • Patients with severe pain or aerodigestive compression symptoms
  • Patients with severe anxiety from fear of possible malignancy